LeanBlog Podcast #78 – Sorrel King, Improving Patient Safety


Episode #78 brings a very special guest, Sorrel King, to talk about systems, communication, and patient safety. Sorrel's 18-month old daughter, Josie, was the victim of a series of preventable medical errors at a world-renowned hospital, passing away in the hospital's ICU. Sorrel channeled her grief and energy into the Josie King Foundation, which works to educate healthcare providers, patients, and families about patient safety and systems improvement. From their website:

The Josie King Foundation's mission is to prevent others from dying or being harmed by medical errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we hope to create a culture of patient safety, together.

Sorrel is also the author of the recently released book, Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe. I think much of what she talks about will resonate with Lean thinkers, as well as anyone with an interest in safer healthcare.


Note: This is an automated transcript and may contain errors.

Mark Graban: 00:20 Hi, this is Mark Graban. Welcome to episode number 78 of the podcast. Today's guest is Sorrel King, the author of the new book Josie's Story, a mother's inspiring crusade to make medical care safe. In 2001, Sorrel's 18-month-old daughter Josie died tragically after a series of preventable errors at one of the world's top hospitals in the aftermath, Cheryl channels her energy not into destroying the hospital, but instead into helping all hospitals learn and make improvements based on what happened to Josie. Sorrel started the Josie King Foundation and has been an influential voice in the healthcare quality and patient safety movement. Well, today we're not discussing quote-unquote Lean per se. I think much of what Sorrel talks about will resonate with lean thinkers as well as with anyone who has an interest in safer healthcare in terms of what's needed from a systems communication and leadership standpoint.

Mark Graban: 01:14 So I want to welcome our very special guest today. Sorel King from the Josie King Foundation. Thanks for taking some time to talk today.

Sorrel King: 01:22 Thank you, Mark. It's good to be here.

Mark Graban: 01:24 So one of the start, first made, if you can tell us about your new book, Josse's story and you know, what you think the, the lessons are that can be learned, you know, from the tragedy that you and your family has suffered through, you know, what are the lessons for health care providers about some of the keys to better patient safety.

Sorrel King: 01:42 So the book just got published a few weeks ago and you know, I wrote, I wrote the book for a number of reasons. I wrote it for the healthcare industry that they will always remember the story and remember the importance of communicating the importance of good teamwork, the importance of listening to the patients, listening to the family, listening to each other. I wrote it for leadership of hospitals so that they will realize the importance of their staff, their docs and their nurses. Saying to them, quality is important. Patient safety is important. Let's prevent these errors from happening. I wrote it for any parents that's ever lost a child. And what am I for my children, for my family, for the bill. Always remember Josie, but I really wrote it for 'em and one of the most important threads throughout the book is I wrote it for anyone, any person who's ever suffered from loss or disappointment. We, we're all gonna suffer from lots of disappointment. It might be death, it might be cancer, it might be a divorce, it might be at loss of a job or bankruptcy. But I think the main message in the book is about taking that bad stuff and figuring out a way to make something good of that. And by doing that, we not only sort of help ourselves, but we can help others. And so that was kind of my purpose in writing the book.

Mark Graban: 03:11 Well, I know I was going to ask you talk about channeling what, what could have been, you know a lot of anger into something constructive as, as you've looked into some of the causes of, of medical errors. We're wondering if you can share some of the things that you learned and you know, what you found that was maybe surprising about y, y incidents, medication errors, preventable errors occur

Sorrel King: 03:34 After Josie died? It, you know, I kind of first, first thing I never really knew was that patients medical errors are happening. I I didn't know eight years ago that 98,000 people die from medical errors every year. Fourth leading cause of death in the country, like a jumbo jet crashing every day. I didn't know that. And you know, that was another reason why I wrote the book to raise awareness within the general public and the book, the main message, the main sort of patient safety message in the book and sort of in, in the work that I do with the foundation is the communication piece and the culture piece. You know, we all know that The Joint Commission states that over 70% of all sentinel events are due to a breakdown in communication. So, so that's my message as a mother. And as a patient safety advocate, Josie died because people didn't communicate. And I'll set up a lot of the problem with a lot of these medical errors. It's not one doctor or one nurse or one misplaced decimal point. It's the system, the breakdown on the system, the breakdown in communication. So that's really kind of my message in the book changed the culture. Leadership needs to speak up, encourage their, you know employees to do something about this.

Mark Graban: 04:54 I know you speak to a lot of hospitals. You've spoken to groups like the institute for healthcare improvement. What is the reaction or, or reactions that you get from medical providers physicians, hospitals, when, when you hear their message how do they respond in terms of what they think they can do or what's actually actually possible?

Sorrel King: 05:18 They, they, wherever I go, I mean, and these, these speaking requests, I don't go out looking for them. They, they just keep coming in with. It's, it's, it seems crazy to me, but everyone is very receptive in improving this culture. It, it seems like wherever I go, I mean, you know, I always these big conferences, patient safety conferences and there's people were talking a lot about it and there's PowerPoint and there's a lot of data and lots of statistics being thrown around out there. And that's all really great. But I think with the health care industry, I think what people are hungry for and what I've learned over the seven years or so that I've been doing this is it is the power of a story. And the power of this story is this seems to be resonating with the health care industry and medical schools and nursing schools and law schools are using the story. The aviation industry is using the story. So I think the story is having a huge impact on on people out there. And and like I said, it, it's, it's changing the culture I people and, you know, communicate better.

Mark Graban: 06:33 Yeah. And that's probably surprising the people where they must assume that a lot of it might be a technological problem and it'd feel so well we just need some new fancy technology information systems, bar coding. But you know, it, it, it is pretty amazing that it comes down to, you know, these very human dynamics. So maybe on the one hand things like that are easier to fix, but maybe on the same time if it was easy to fix, people would have a better culture in place already. What kind of thoughts have people shared with you about the, the difficulty, the gap between understanding that we need to improve the culture and, and what people are actually do at what they're able to do to, to make real change in, in their culture to improve safety. Right.

Sorrel King: 07:21 I think it's hard. I mean, it's kind of a gray area. I think it's a really hard thing. I want to go back a second, you kind of got me thinking when you were talking about technology and bar coding and all of that which is all really, really great. But I think if we can change, if we do that without changing the culture, then I don't think it will be as effective. But if we can change the culture along with doing that, then then I think we will really be on the right track. I think changing a culture from what I've learned and from what people tell me sometimes people say, well, you're like a dog running up the hill with a rope and it's now pulling a locomotive. They say, people say that changing the culture is like the hardest thing to do, I guess.

Sorrel King: 08:13 But I think it's, I think it's happening. I think there are a lot of people that are out there doing some really great patient safety work and I think it's hard for the healthcare in the street because it is hard to measure. I mean, how do you measure potential lives saved or I, you know, how to, it's kind of fuzzy and kind of gray and kind of vague sometimes. But I mean that's, that's, I just try to get the message out there. I tried to inspire caregivers to to think about it and you know, why, why we're billing what we're doing, why are we, why are we having this new technology? Because we've got to change the culture. It's all neat to me it's $15 for a real interrelated.

Mark Graban: 08:53 Yeah. And it talks about the fuzziness, the numbers. You know, people often ask me, you know, this 98,000 number, where does it come from? I think part of the problem is that nobody really knows for certain if it's 75,000 or 125,000 or, you know, there's different studies. It's all based on you know, somebody whose best determination and then extrapolating, you know, across the whole population. But I think what, I think you're right were regardless of the exact number each of these preventable errors and cases of patient harm or even patient death is a, you know, is one tragedy to many. And, you know, it doesn't get the attention that it would get to the analogy that you drew about, you know, a plane crashing every day. Unless there's a story, like the one that, that you're, that day that you tell statistics can be hard to translate into something to get the general public aware of or to get, you know, the healthcare providers and, and probably, you know, more importantly the hospital leaders and engaged around to improve culture. So I think that's, it seems like one of the challenges

Sorrel King: 10:05 it's the whole awareness thing. It's still blows my mind and I, I think about it like you and I, we all know, we know what mothers against drunk driving though we know what MADD is all about. I mean, we all know what a great organization that is. We know about that organization because we're going to get in a car this afternoon and we're going to hope we don't get hit by a drunk driver. And we all know about drunk driving. We all know that I'll be car accidents. I think what people die from medical errors then do die from drunk driving. And I, yeah, I don't, I, it just blows my mind that the general public still doesn't quite get it. No. Mark my new book a couple months ago, my publisher called me up and said, hey Sorrel, Good Housekeeping. It's going to do, you know, wants to feature your book.

Sorrel King: 10:51 And the October issue. That's right now. But this October. And I remember saying to her, well gosh, I was really hoping for a vogue. I really want, you know, my 13 year old would think I was so cool, but my, but the publisher said, you know, Good Housekeeping, 13 million people circulates, have 13 million, zero to 2 million Good Housekeeping's the heartland of America. So you know, through this book, which to me, this book is just another tool – a foundation tool – in my toolbox. But this book, you know, some Good Housekeeping and the woman, a mother in Des Moines, Iowa is reading isn't a doctor's office. And she's probably looking at good housekeeping and she's reading about medical errors and how to prevent them and what patients and families can do and what healthcare providers do. And so, you know, and hopefully in my small way, this book is raising awareness and so many other great books out there, Jerome Groopman and Atul Gawande, Bob Wachter, great, great books. But unfortunately I don't think that some people in the general public not pick, pick those books up because it's not something done the top of their head. But hopefully Josie story mothers and people can kind of relate to it because it's a, it's a mother who's writing a book, you know.

Mark Graban: 12:04 And in the book too, you give advice, direct advice to a parent or anyone who has a loved one going to the hospital of, of what precautions or steps that they should take. I'm in pretty concrete ways to help make sure that the environment they're in is a good one or that, you know, errors are less likely to occur. What can people do?

Sorrel King: 12:28 Right? Absolutely. The book in the, in the back of the book, there's a resource guide, which I was really psyched about. The resource guide is split up into two sections, one section, and for patients and for families. The other section is for health care providers. And it's pretty much sort of steps on, you know, how to manage for the patient's families, how to manage your stay when you're in the hospital and what you do. And when something goes wrong, what do you do? How do you get medical records if you have to get a lawyer, how do you hire a lawyer? How do you go about it? What do you do? And then for the healthcare providers, it's just, you know, programs and things, you know, that they can do to communicate better and change their culture within their organization. But the whole book, I mean, you know, the whole book is about sort of that, you know what I'm saying?

Sorrel King: 13:15 And so if you read the patient reads the book there and they don't read the resource guide, they're definitely going to come away with, wow, when I go to the hospital, I've got to pay attention. Wow. I can't ever be afraid to speak up. I've gotta, I should try to have a an advocate person with me. I should write down, I should document stuff. I should keep track of inflammation. So that's kind of all throughout the whole book. And then this is the same thing for the health care provider. I'm new the whole bit about the importance of leadership doing what they need to do. And then important, you know, what nurses can do and doctors can do in rapid response teams and family aggravated rapid response teams and transparency and disclosure, the importance of all of that. So, so all of those threads are throughout the book, but it's all sort of tied up into a nice little package and the resource guide.

Mark Graban: 14:04 Well that's good. It's good to hear that. There, there, there's something people can take away from the book. Cause we're, we're all gonna end up, it's for very likely what we gonna have a loved one in the hospital this year. And it's very important. I'm glad that you're sharing that for people, for their loved ones. Well on the final thing to talk about here on, you know, you channeled a lot of your energy after Joseph's death into the foundation, the Josie King Foundation. I just wonder if you could tell the listeners a little bit about some of the main activities and things that you're able to accomplish through the foundation.

Sorrel King: 14:40 Right. So, so the foundation really kind of just stems from a settlement. So, you know, Hopkins offered us money for the, for the death of, of our, our, our daughter like this is all in the book. You know, we didn't want the money. We didn't, we by taking the money we'd be letting them off of her up, blah, blah, blah. But long story short, we took the money and we've decided to do something for Josie. We do something good with that. And we created the Josie King Foundation. Our mission is to prevent patients from being harmed or killed by medical errors with simple mission. And we've got lots of gosh, different programs kind of going on. You know, money comes in from, from donors and sponsors and from people healthcare to three people who purchase a DVD and then the money goes really back out into the healthcare industry.

Sorrel King: 15:32 We've done a lot of family activated rapid response team projects. You've done a care journal project for patients and families you know, a little journal for them to take to the hospital. So that they can keep track of information and steps on how to manage your stay. Our latest project, which I'm really excited about is called the nursing journal. And this is also in the book of few years ago. You know, I, I, we kind of realized that, you know, it's not just the patients and the families that suffer from an adverse event. It's, you know, the doctors and the nurses really, really, really suffer too. And this is as a PR program really different. We started, we were going to start with nurses first. There's a nursing shortage. Nurses are stressed out that, you know, they're being pulled in the middle of a million different directions.

Sorrel King: 16:20 And I think they've got a really tough job and they're just, I admire them so much. So we gave some money to 'em for some research to be done on the therapeutic benefits of expressive writing. And long story short, as, as I was working on this project, I was kind of, I'm struggling with that. God, something's not right. Something's not right. And then I said, oh my gosh, I'm not a nurse. How am I supposed? I mean, who am I to tell nurses what's good for them? So we sent out an email to nurses all over the country saying, Hey, send us your tips on what you do to deal with the stress of being a nurse. And it was so cool because we got tips from nurses all over the country on how they deal with it. And that's part of the Nursing Journal workbook.

Sorrel King: 17:04 But so it's great. I mean, that program's really just two weeks old. And as I've traveled around the country talking about the foundation and talking about the book I get to talk about the nursing journal and all these other projects and it's gotten, it's gotten really great response so far for, from the nurses out there. And I'm really excited about it. But our main, you know, the main goal, the main focus of the foundation is, like I said earlier, the communication and the culture piece. And, and that's what we do. I do all public speaking. I meet with medical students and nursing students and residents and law students and we've got a disclosure program that we've created a disclosure program to help pop hospitals you know, figure that's a could sort of explain to them the importance of transparency and how to talk to a family after there's been an adverse event and you know, lot, lots of other things. But that is a pretty, pretty much the top few on my list right now.

Mark Graban: 18:06 Well, it, it, it's great work and I'm glad that you're doing it. The DVD that you mentioned. I would recommend, especially to listeners who are with a health care organization that you know, your organization can, can buy that DVD, Joseph king.org a. It's very powerful. DVD of Sorrel. I'm giving a speech, I'm talking about Josie's story and hopefully it's something that people will purchase to help not only spread the message of improving patient safety, but to also help fund the good works going there at your foundation. So, sir, it's certainly an honor to have you with us today. Well thank you for your time and yeah, it, do you have any final thoughts to wrap up for the audience? Anything else you'd like to share?

Sorrel King: 18:55 You know, read Josie's Story if you're in the healthcare industry is, it's great because doctors are coming up and they're saying, oh yeah, we gotta buy these for our residents. Oh, our medical students need these. Oh, we got to get these to our board members. Oh, hey, can you write a dedication to my CEO? Or, Hey, our patient's safety officers need to read this book. So it's having a really, it's having the effect that I wanted it to have on people. I think it's helping clean the culture, helping inspire people to continue their really, really great work out there. And you know, I think, I think if people are saying it's a good read, they like it, you know, it can be read it, it was done in a couple of hours. It's not real thick, long book, but I'm, I, you know, I just appreciate all that people are doing out there. I think really great things are happening and we're on the right path and it's all, it's all good and thank you for having me, Mark.

Mark Graban: 19:50 Well, certainly. And thank you Sorrel King from the Josie King Foundation. It's great talking.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.



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